Provider Demographics
NPI:1528198546
Name:DEWALDEN, CAROLYN (PA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:DEWALDEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 STRIHAL LOOP
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34787-8958
Mailing Address - Country:US
Mailing Address - Phone:407-877-0984
Mailing Address - Fax:
Practice Address - Street 1:10131 W COLONIAL DR
Practice Address - Street 2:SUITE 4
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4221
Practice Address - Country:US
Practice Address - Phone:407-298-4910
Practice Address - Fax:407-296-2638
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9102038363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant